Clearing the Cervical Spine in Obtunded Patients

Tyler J. Harris, BA; C. Craig Blackmore, MD, MPH; Sohail Mirza, K. MD, MPH; Gregory Jurkovich, J. MD


Spine. 2008;33(14):1547-1553. 

In This Article


We identified 590 patients who met the inclusion criteria. After excluding 223 patients with fractures and other exclusion criteria ( Table 3 ), the study sample consisted of 367 subjects. Clinical characteristics of subjects are summarized in Table 4 . Mean age was 40.2 years (standard deviation 20.8) and 76% of the subjects were male. Mean Injury Severity Score (a validated overall scale predictive of mortality in trauma patients[7]) was 24.5 (SD 10.0) where >15 is considered severely injured, and Glasgow Coma Scale (a validated assessment of central nervous system function) score was 5.9 (SD 3.4), where <8 indicates high probability of poor outcome.[7]

All study subjects underwent upright cervical spine radiographs. The upright radiographs did not identify any additional injuries. Further evaluation after the initial cervical spine CT identified 1 additional cervical spine injury, for a probability of a false-negative result of 0.3% (1/367). Neurologic deficit was identified in a patient after the patient gained consciousness and was able to cooperate with neurologic physical examination. Subsequent MRI confirmed spinal cord contusion and posterior ligament increased signal consistent with acute injury (Figure 2). The injury was considered stable and treated nonoperatively with cervical collar immobilization and rehabilitation.

CT and MR images of the single injury identified by subsequent evaluation after an initial normal c-spine CT (A, CT; B, spinal cord signal change on T2 MR; C, posterior ligament increased signal on T2 MR).

Complete time data on spine clearance were available in 328 subjects (89%). The mean time interval between initial normal c-spine CT and final spine clearance was 2.6 days (SD 3.4). Time spent in cervical collar immobilization and spinal precautions exceeded 48 hours in 138 subjects (42%), 7 days in 22 subjects (6.7%), and 14 days in 4 subjects (1.2%) (Figure 3). Duration of excess cervical immobilization was a total of 886 person-days.

Delay in spine clearance due to requirements of upright radiographs or clinical examination after an initial normal c-spine CT.

All subjects had an initial c-spine CT that was interpreted as showing no injury. A total of 459 additional imaging studies were obtained to establish spine clearance in the study subjects. All subjects also had upright cervical spine radiographs as required by spine clearance policy (n = 367). Additional cervical spine radiographs were obtained in 60 subjects (16%), repeat cervical spine CT in 3 subjects (1%), and c-spine MRI in 28 subjects (8%).


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